Author: Qualify Health

How hospitals and oncology centers can reduce bad debt through Patient Assistance Programs, Copay Cards and Foundations

The ultimate goal of a hospital or healthcare organization is to provide exceptional patient care; however, making a profit is necessary to achieve that goal.

According to a survey from Sage Growth Partners, a healthcare research firm, more than a third of hospitals rack up at least $10 million in bad debt each year, and half do not expect to recover more than 10% of it from payors or patient out-of-pocket expenses.

Understanding Out-of-Pocket Expenses can be Complicated

Healthcare providers are more challenged than ever when providing quality care to an increasing number of patients facing unaffordable out-of-pocket costs due to high deductibles, being under-insured, or uninsured. With each of these financial hurdles, hospitals and medical practices face a tough decision:

1. Send the patient a constant stream of letters and notices informing them of their outstanding balance due

2. Write-off the payment as bad debt and carry it on their balance sheet with the expectation that payment is unlikely

Most patients’ bad debt accumulates because a patient cannot afford the balance after their insurance has covered its portion of the expense. Most medical insurance plans only cover part of the fee due to the provider, leaving the patient with out-of-pocket costs. These out-of-pocket costs include deductibles, coinsurance, and copayments.

Patients are often unaware of their out-of-pocket expense before their treatment, and in many cases, even if they are aware, they are unable to afford them. While it is ideal for a provider to collect all out-of-pocket expenses upfront, this is not always possible, especially for costly services like chemotherapy, GI infusions, and other expensive in-office injectables. The insurance carrier processes the medical claim first to calculate the patient’s responsibility and then reports it back to the provider on the explanation of benefits (EOB). It is then up to the provider to collect these payments by billing the patient.

Most organizations offer various options to make the payment process easier via patient portals and electronic payment options. However, these options are beneficial only if your patient can afford to pay. If the patient cannot afford their bill, they may qualify for a payment plan or financial assistance. Unfortunately, this extra step is not always enough, and the debt starts to mount.

Improving Cash Flow Management

Cash flow management is essential to all healthcare organizations’ viability, and their accounts receivable days are under constant measurement. Nearly all healthcare organizations bill insurance regularly to ensure ample cash flow and proactively send out a series of notices to patients to settle outstanding accounts. In these notices, the patient is instructed to submit payment within a given time frame. If payment is not received, the provider will send the patient to collections (likely lowering patient satisfaction scores). However, sending a patient to collections does not guarantee payment and usually just reduces the provider’s reimbursement because the collection agency imposes a fee for their services.

Using a billing and collection process as the only means to collect monies owed is inefficient and usually unsuccessful, particularly when patients cannot afford their bills. While it is essential to maximize collections, organizations must be careful not to take collection practices to an extreme. They risk alienating patients, receiving more patient complaints, and ultimately reducing collections.

There is a Better Way

There are many ways to avoid the ‘bad debt’ cycle that your practice might find itself in, particularly when helping patients cover their infusion and in-office drug costs. By taking advantage of many of the manufacturers, foundation, and non-profit support programs, it is likely that your patients will be able to find the help they need to cover their out-of-pocket costs.

Q Consulting Support Services – Patient Financial Advocacy

Q Consulting Support Services (QCSS) offers financial advocacy to patients through many financial assistance programs. We work closely with your clinical team to identify patients who are uninsured, underinsured, have high-out-of-pockets expenses, or high balances that qualify for assistance for their prescription drugs or infusion drugs. Below is a list of the most frequently used financial assistance routes; however, we are not limited to these options. QCSS has a comprehensive database of financial assistance programs we use to ensure we exhaust all avenues for our patients and clients.

Financial Advocacy Options:

Manufacturer Copay Card Assistance:

Drug Manufactures offer Copay Card assistance programs. The program’s purpose is to help people with commercial or private insurance cover their deductibles, copays, and coinsurance directly related to their prescription drugs’ cost.

Patient Assistance Programs:

These programs, frequently called PAPs, are designed to help those in need obtain their medications at no cost or very low cost. Many, but not all, pharmaceutical companies have PAPs.

Foundation Assistance – Copay and Premium:

Foundations offer financial assistance to those suffering from Chronic or Life-Altering Diseases when insurance is not enough to cover the treatment. Foundations help fill the gaps by assisting patients with their out-of-pocket expenses or covering costly insurance premiums.

Q Consulting offers a team of professionals that will find, source, and manage the much-needed financial assistance available to many of your patients. QCSS has a tremendous track record in reducing bad debt for providers through our financial advocacy program. One of our current clients reduced their bad debt by 70 percent within six months. Through this period, QCSS collected over $300 thousand in copay card assistance, $600 thousand in PAP (Free Drug/Replacement) assistance, and $200 thousand through other funding sources – adding up to over $1 million in financial advocacy found for this client.

If given the opportunity, QCSS will successfully help your organization recover patient balances through our financial advocacy program, ultimately reducing bad debt, increasing profits, and boosting available cash flow. We take the burden off your team so they can focus on what they do best-providing exceptional care to your patients.

Hospitals can improve infusion center profitability by focusing on one area – the Insurance Verification Process and Prior Authorizations.

Numerous factors have contributed to the shift of outpatient infusion services from the private practice setting to the hospital outpatient setting. As this trend continues, hospitals must focus on one area that can help guarantee the center’s profitability: verifying patient insurance benefits.

Many outpatient hospital-based infusion centers struggle to be profitable due to a lack of resources required to verify patient insurance. The verification process consists of three components: Verification, Eligibility, and Prior-Authorization.

Let us break down each component:

Step 1: Insurance Verification:

Does the patient have insurance, and are the infusion services covered under their plan? The intake department completes the verification process upon admission by calling the insurance carrier (which can be time-consuming), through the EMR system – if offered, or through another platform like Availity.

Verification of benefits ensures the patient has coverage for the specified treatment plan and indicates if prior authorization is required.

Step 2: Eligibility

During the insurance verification process, you must also determine the plan’s eligibility period. Is the patient eligible for services during the time that you will be performing the infusion? Completing this step before EACH infusion ensures there is no lapse in coverage or that the policy is still active and has not been terminated (which can happen for various reasons).

Step 3: Prior-Authorization (PA):

Once you have determined that the patient’s insurance plan requires prior authorization, you must ensure the patient meets the plan requirements. This process generally requires sharing information from the patient’s medical record. Providing the medical record will establish medical necessity and explain why the physician prescribed one drug over another more affordable option– possibly due to previous product failure or patient allergy. The health insurance company will review the physician’s recommendation and either approve or deny the authorization request.

It is imperative to note that medical care will need to be approved by the insurance carrier before treatment is received. The medical claim will be denied without prior authorization.

The prior-authorization process can be burdensome. According to the American Medical Association (AMA), 9 in 10 physicians find that prior authorizations have a negative impact on patient outcomes and believe the burden associated with PAs has increased over the past five years.

Revenue Cycle Management (RCM) and Prior Authorizations

Prior authorizations are a pain point for providers yet are crucial to the revenue cycle and clinical care operations. The RCM process ensures that patients can access the necessary care and providers get paid for delivering services.

Patient Revenue is tracked and managed through the RCM process, starting at the initial encounter through to the final payment. The cycle encompasses all administrative and clinical functions contributing to capture, management, and collections from the patient and their insurance provider.

Revenue Cycle Management is critical to operating a thriving infusion center; It requires the strategic management of Insurance Verification, Eligibility, and Prior Authorization. With the rising cost of drugs, shrinking margins, and overall changes in the drug and healthcare industry, providers need to be sure they have a knowledgeable team who can sustain a healthy revenue cycle.

Everyone plays a vital role in ensuring correct reimbursement for these high-cost drugs – but most organizations or infusion centers do not have adequate staffing or additional resources for such an undertaking.

Financial Advocacy – Supporting a Healthy Revenue Cycle

Q Consulting Support Services (QCSS) provides a team of financial advocates that can help the infusion center maintain a revenue cycle that maximizes revenue collection while keeping the patient at the center of each transaction.

QCSS is a full-service insurance verification, prior authorization, financial counseling, financial advocacy, and specialty pharmacy management program.

Most importantly, we begin by verifying insurance benefits so both the provider and the patient know the out-of-pocket expenses related to the planned treatment. Once our financial advocacy team identifies patients that are under-insured or have high out-of-pocket costs, we determine which supplemental coverage sources are available to help manage their healthcare costs and ensure the provider receives payment for services delivered. We continue to oversee the entire reimbursement process, whether for a Manufacturer Copay Card, Foundation Assistance, or Free Drug through a Patient Assistance Program.

QCSS will also manage the Prior Authorization Process to guarantee that patients get access to the medications they need on time – alleviating the clinical team’s administrative burden and allowing them to focus on patient care.

The revenue cycle in healthcare is complex, requiring continuous process improvements to keep pace with the ever-changing industry. QCSS would welcome the opportunity to partner with your infusion center to improve your revenue cycle and assist your staff and patients with all their financial assistance needs.

The negative impact of financial toxicity associated with cancer treatment related out of pocket cost.

Cancer Patient Risk Factors for Treatment-Related Financial Toxicity

Cancer is one of the most expensive medical conditions to treat in the United States. Patients that have been diagnosed with cancer will likely need multiple types of therapies, and many of these come with high out-of-pocket costs: chemotherapy, radiation, surgery, hospitalizations, systemic treatments, oral chemotherapy, and cancer-related prescription medications.

Further, cancer patients and survivors are often unable to work due to their treatments and overall health, placing more pressure on their financial circumstances.

Financial toxicity is how the healthcare world has come to define the financial hardship that patients experience due to their high out-of-pocket costs, which many have reported to be more than 20% of their annual income!

6 Factors That Increase the Likelihood of Patient Financial Toxicity

1) Age: < 65 years old

Cancer survivors under the age of 65 years are more likely to be financially impacted from cancer. This could be due to:

1. The lack of savings and assets

2. Other financial responsibilities like raising children

3. Not having health insurance

4. Having high-deductible plans with high out-of-pocket costs

2) Future Income Potential and Job Performance

This younger the demographic, the more likely their future job potential will be negatively impacted. Cancer treatments can impact a patient’s ability to work due to their therapy and overall poor health.

Cancer treatment requires frequent days away from work due to either treatment times that might include 4-hour chemo infusions, which decreases the patient’s work hours and overall productivity. Given this reality, cancer patients will experience difficulty returning to the workforce, often face job losses, reduced income, and employment-based health insurance loss. Cancer diagnosis and treatment takes a toll on the patient physically, mentally, and emotionally, diminishing the household productivity and income.

3) Income Level

Lower-income households are at a greater risk of treatment-related financial distress. The indebtedness of a patient before their diagnosis plays a significant factor in driving up financial toxicity. Cancer treatments will increase the patient’s risk of accruing more debt and often lead to difficulty paying for living expenses and an eventual filing for bankruptcy.

4) Other Chronic Conditions

Cancer survivors are more likely to have chronic conditions such as heart disease, high blood pressure, stroke, emphysema, high cholesterol, diabetes, and asthma, which alone are typically associated with substantially higher medical expenses. Layering a cancer treatment on top of these other expensive conditions exacerbates the financial toxicity levels that a patient is facing.

5) Advanced-Stage, Recurrent, or Multiple Cancers

The type and stage of a cancer diagnosis determine the treatment paradigm for a cancer patient. Advanced-stage, recurrent, and multiple cancers require chemotherapy and radiation that carry high out-of-pocket costs. Treating aggressive cancer or cancer with a poor-prognosis commits the patient to invest their financial resources for treatment and physician visits. Additionally, the patient will need to invest their time to attend appointments – which usually occur during working hours.

6) Health Insurance

The patient being uninsured certainly places them at risk for financial toxicity. However, the type of insurance coverage the patient has can increase the likelihood of economic hardship due to high maximum out-of-pocket and high deductible plans.

Patients with Medicaid or Medicare have a high financial vulnerability due to lower income levels and fewer savings and assets.

Financial Distress Reduction

The sharp and steady rise in cancer treatment costs has meant that patients need protection from financial toxicity. Financial toxicity can negatively impact the patient’s life outside of the clinic and interfere with the planned treatment strategy and overall recovery. As with any heavy financial burden, high medical expenses related to life-saving treatment carry the same destructive force and pressures and negatively impact the patient’s life, future, and ultimate outcome.

Patients with high financial stress show the following characteristics:

1. Decreased treatment adherence rate and increased prescription abandonment rate due to prescription copays and out-of-pocket amounts.

2. Lower Patient satisfaction scores

3. Reporting of more symptoms, including pain and feelings of depression.

Savvy practices that recognize the industry trend of financial toxicity on treatment outcomes, patient satisfaction, and overall general health will look for ways to solve these problems for patient s through financial advocacy and alternate solutions.

How Q Consulting Can Help

At Q Consulting Support Services, we provide the strategy, workflows and technology needed to obtain a more comprehensive picture of the patient’s financial status and find solutions to their financial toxicity burden. Our successful system decreases the patient’s out-of-pocket responsibility and reduces bad medical debt through unconventional patient funding sources. We can fill in the gaps through patient financial advocacy, so patients feel taken care of physically and financially to drive up patient satisfaction scores.

GI infusions for diseases like Crohn’s Disease are often required monthly and can be financially burdensome to patients. QCSS removes the financial burden from the patient by managing the entire copay card process.

Patient Background

Many patients we assist are dealing with chronic conditions requiring expensive medical treatment. This patient has been diagnosed with Crohn’s disease of the small and large intestines with complications. Crohn’s disease is an inflammatory disease affecting the digestive tract and currently does not have a cure. Infusion drugs can help manage the disease symptoms, but the treatment is expensive – even with insurance.

Financial Toxicity of Treatment Costs

Mr. R is a 22-year-old recent graduate just entering the workforce. He is still on his parent’s insurance plan, so his dad assists him with his medical care and decisions. His insurance plan has an out-of-pocket (OOP) maximum of $6,000 that he is responsible for paying annually. He is getting monthly infusions and will be accountable for each infusion’s OOP expenses up to his $6,000 insurance maximum. His first infusion had an OOP expense of $2,857.20, and his second had an OOP expense of $666.68.

The QCSS Copay Card Solution

Mr. R’s father called to discuss how Q Consulting Support Services (QCSS) could assist them with his son’s OOP expenses related to his Remicade infusions. QCSS’s Financial Advocacy team explained that we would immediately enroll Mr. R in the Remicade Copay Card Program. Moving forward, we will manage the reimbursement process from initial claim submission to receipt of payment directly to the provider’s office. Mr. R’s father could not believe what he was hearing and was highly appreciative of the services we offer, free of charge, through the hospital infusion center. The patient’s father said, “I know we have only been speaking for 8-minutes, but I think you are going to be my new best friend.” With one conversation, QCSS was able to save this family over $3,500.

The Typical Copay Card Reimbursement Process

A typical pharmacy copay card requires less patient involvement. The patient gives the copay card to the pharmacy, the pharmacy bills the insurance first, and then applies any remaining balances to the copay card. In contrast, the copay card process for infusion treatments can be burdensome and complicated – this is where QCSS steps in.

Usually, after a patient like Mr. R receives treatment at an infusion center, the practice will bill the patient’s insurance, and the insurance carrier processes the bill. As a result, the carrier generates an Explanation of Benefits (EOB), indicating payment to the provider and informing the patient of any OOP responsibility.

Each copay card program is different; however, the process for claim submission is generally the same. The patient has a certain amount of time to submit the EOB to the copay card program to secure the copay card payment benefit. The patient is then responsible for submitting the EOB, and many patients do not know what this is or where to find it. To ensure the claim is processed correctly, the patient must include the following information:

1. Reimbursement Claim Form
   1. Patient Demographics
   2. Name of the insurance provider & Member ID
   3. Facility Name, Provider Name, and NPI number
   4. Date of Service (DOS)
   5. Name of drug or J-code
   6. Amount billed, allowed amount, the amount paid to the provider, and patient responsibility.
2. Claim Form
   1. UB4
   2. CMS 1500 HCFA
3. Explanation of Benefits

Once the patient has gathered the claim information, the patient submits the claim by fax, mail, or online portal to the copay card program. Upon submission, the program verifies the claim. The copay card payment is processed – processing time can vary between hours, days, and weeks – regular phone calls to the copay card company are required to ensure the claim is processing correctly, and no further action is required.

After the payment is approved, the program releases the funds via check or credit card payment. If this process is not convoluted enough, the patient is responsible for coordinating payment to the provider. Suppose the payment is loaded to a credit card. In that case, the patient is responsible for calling the provider, giving them the date of service and amount due, then providing them the card information to process the payment. If the program issues a check payment, the patient can coordinate with the copay card company to have the check sent directly to the provider. It is then the responsibility of the patient to ensure payment is received and applied to their account.

Improving Patient Satisfaction

Mr. R was thrilled with the services provided by QCSS on behalf of the infusion center. QCSS manages the entire process – we identify EOBs with patient OOP expenses, then submit them to the copay card manufacturer on the patient’s behalf, and monitor processing to ensure payment is approved. If the program generates a check payment, we notify the provider of the check number and amount paid. If the program loads the payment to a copay card, QCSS communicates with the provider’s billing office and has them process the charge. QCSS updates Mr. R throughout the process, and any decision that is not in our patient’s favor is appealed and rectified. Our approach is entirely seamless, relieving the patient of this burden while ensuring payment is received for their bills– which is why the provider’s office loves the service!

Healthcare expenses related to diseases like Crohn’s Disease Mr. R” s, which require monthly infusions, are financially burdensome to patients and their families. This financial toxicity can create and add additional stress to an already stressful situation. Alleviating our patient and his family from the financial burden related to this treatment will allow him to continue treatment without delay and focus on the more essential things in life.

A how-to-guide to troubleshoot financial advocacy for cancer infusion center patients facing financial distress.

Patients who have insurance and are on expensive infusion therapy and oral chemotherapy medications must meet high out-of-pocket maximums before their benefits cover the treatment cost. Many patients find themselves with out-of-pocket maximums that exceed $6500 when seeking treatments for cancer or other infusion-related treatments.

As many headlines have noted, patients without insurance or prescription coverage face a shocking bill for their life-saving prescriptions. The retail price of a 30-day supply of oral oncology specialty medication is double and triple the out-of-pocket maximums – and can be as much as $16,000 for a month supply.

Fortunately, there are charitable organizations and drug manufacturer programs that provide disease-related grants to help the patient with out-of-pocket expenses. However, these disease funds are in high demand and become fully funded quickly. For example, when a breast cancer fund opens, it is usually only open for around 2-hours before all of the funding dries up and the fund is closed again. For patients who are fortunate enough to secure disease-based funding, they find that with the high cost of treatment, the grant will usually deplete quickly, and they then have to try to find additional financial assistance.

Factors that determine the route to take for patient financial advocacy:

Diagnosis

There are many disease funds available for patients depending on their diagnosis. The organizations that provide the grants do have income requirements for the applicant and restrict what services they will reimburse. If a patient can obtain funding and depletes the grant balance before treatment is complete, some organizations will only allow them to apply for additional funding every 12 months. This is highly problematic for patients who lack the extra coverage of a Medicare Advantage plan or are without prescription coverage.

Therapy and Treatment

The patient’s cancer diagnosis and staging determine the type of treatments they will be receiving. Depending on the patient’s treatment plan and associated therapies, copay cards are available for these high-dollar specialty medications and infusions drugs. The copay cards are obtained directly from the manufacturer and will help reduce the patient’s out-of-pocket responsibility. There is no income requirement for the application.

Insurance

Patients must have a private or commercial insurance policy for copay card programs. Patients who have government health insurance, such as Medicare and Medicaid, are not eligible for the copay savings programs. Disease funds will also restrict applicants to specific grants depending on what their insurance is.

Copay Accumulators

Insurance companies have started to push back at patients using copay cards by not allow it to count towards their plan out-of-pocket responsibility. Once the patient has used the copay card’s max assistance amount, they are left facing the large unpaid policy deductible.

Patient Income

Patient access programs and disease-based grants have income requirements to qualify for assistance. Some patient assistance foundations clearly define their income eligibility requirements, and some keep the requirements private. Applicants have to fall within the income requirements and proving a certain percentage of the patient’s income is spent on medical expenses. Assistance programs will ask for proof of income, bank statements, and receipts to verify the financial information provided on the application.

How QCSS Can Help

Our years of experience at Q Consulting Support Services give us the knowledge to troubleshoot and strategize how to obtain patient funding through unconventional sources. We proudly help patients, pharmacies, infusion centers, and health systems find the right regardless of income and manage the entire process, from sign-up, appeals, and ongoing charges. We work side-by-side with the patient, their clinicians, and family members and address each of the requirements needed to qualify and receive assistance. This starts with the sign-up process, through to EOB and charge submission, to check or copay collection and ensuring the charges are paid – and submitting appeals in cases where needed.

CONTACT US TO LEARN MORE

The Inaugural Survey of Infusion Copay Cards

The Inaugural Survey of Copay Manufacturer Programs

Q Consulting Support Services conducted a survey of infusion center staff who work regularly with copay programs and after tabulating all of the responses, have come up with the Top-10 Manufacturer Copay Assistance Programs based on five criteria.

The easy winner was Jannsen Carepath, who had the top score in all categories except for one. At the bottom was Zoladex, who failed on most levels, but was particularly weak when it came to the ability to secure payments.

1. Ease of Copay Card Enrolment

The winners of this segment all had two key ingredients

1. Online ability to submit information for approval – particularly via a portal
2. Immediate Notification of approval

Most of the manufacturers have a portal program or other online programs.

The two programs that performed poorly in this category was Pfizer enCompass, which requires a paper submission via fax and was described as ‘frustrating’ to almost all respondents. The Merck Access Program was also at the bottom of this group with respondents noting that ‘it can take as long as a week to receive notification of approval into the program’.

Several comments were also made regarding Amgen’s First Step program which received comments like “a great online service with immediate notification of approval” but the ‘requirement of a social security number make it difficult for staff to easily sign up the patient’ as this information isn’t something that always sits at their fingertips.

2. Ease of Copay Claim Submission

A portal is the preferred method of submitting the Explanation of Benefits, and other items that copay manufacturer programs request. Janssen is the clear winner and the only one to score a perfect score for this category.

The bottom of the pile for this category was Zoladex and most comments revolved around how many times a fax needed to be submitted – “in multiple follow-up calls to check on status, they always tell us that the full fax wasn’t received and another one needs to be resubmitted”.

Another weak performer in this group was Coherus Complete whose fax number is frequently busy and requires multiple attempts before a fax makes it through. It took one respondent 2-days of trying before the fax was finally accepted

3. Time to Copay Approval

With the exception of Zoladex (which can take over a month), most copay manufacturer programs have between a 3 and 7-day approval timeframe. Again, portals are preferred as the user can check on the status of the approval without having to call for status updates.

4. Notification of Copay Payment Approval

This is where the portal was strong again – being notified immediately via the portal was the preferred method. However, Amgen FirstStep scored high marks, despite receiving notifications via fax, because the notification includes the details of the payment and whether it is being made by check (for which they include the check number) or copay card (for which they include the credit card number and CVC#.)

Many of the others really require constant follow-up for approval details, which was a big frustration to the survey respondents.

5. Customer Service

In general, every copay card assistance program has excellent customer service, with representatives that are very knowledgeable and helpful. Entyvio and Janssen lose one star here because the representatives have struggled occasionally with questions – particularly as it relates to the portal.

About Q Consulting Support Services

Copay Assistance Programs lessen the patient’s financial burden, making it easier for them to obtain their prescription and ensure that the appropriate treatment is attainable.

Q Consulting Support Services specializes in the management of Copay Card programs. Our dedicated staff partners with clients ranging from small oncology practices to the country’s largest healthcare systems. Our Support Service team enrolls the patient into the Copay Card Program, monitors and submits EOBs with patient out-of-pocket expenses, and follows up on any denials to ensure payment is received promptly. Ultimately, increasing patient satisfaction and reducing the financial burden on the provider’s office or facility by guaranteeing patient out-of-pocket expenses are obtained, which reduces bad debt and increases revenue.

CONTACT US TO LEARN MORE

A quick-reference guide for oncology practices to identify cancer patients at risk of financial toxicity.

• Financial Toxicity of Cancer Treatment & Survivorship.pdf

Risk Factors for Cancer Patient Financial Toxicity

Financial toxicity is how the healthcare industry has come to define the financial hardship that patients experience due to their high out-of-pocket costs.

Age: Patients Who Are Less Than 65 Years of Age

Age is one of the biggest risk factors in determining the financial burden of treatment. Cancer patients that are less that 65 years old are more likely to be financially impacted by treatment than those who are 65 and older. Why?

1. <65 Years Old is Working Age

Cancer treatment requires frequent days away from work due to therapy. Chemotherapy infusion times can be as lengthy as 4 to 8 hours long. The patient also has to deal with the treatment-related side effects that decrease their work hours and overall productivity.

2. Lack Savings and Assets

Younger cancer patients are vulnerable to financial distress because of a lack of savings and assets that are accumulated during working-age

3. Other Financial Obligations

Cancer patients that are <65 years old have other financial responsibilities such as childcare, education, mortgage/rent, and high household expenses associated with raising a family.

4. Lack Insurance or Carry High-Deductible Plan

Younger cancer patients lack the protection of Medicare. Decreased work hours reduces employment based insurance options, placing some without insurance or with high-deductible plans.

How Your Practice Can Help Its Cancer Patients

At Q Consulting Support Services, we provide the strategy, workflows and technology needed to obtain a more comprehensive picture of the patient’s financial status and find solutions to their financial toxicity burden. Our successful system decreases the patient’s out-of-pocket responsibility and reduces bad medical debt through unconventional patient funding sources. We can fill in the gaps through patient financial advocacy, so patients feel taken care of physically and financially to drive up patient satisfaction scores.

Financial Advocacy Programs assist hospitals, infusion centers, and cancer care clinics gain access to financial assistance for oncology patients to cover unaffordable out-of-pocket expenses to reduce the treating institution’s bad debt and improve patient satisfaction.

Patients with cancer often face financial hardships or financial toxicity, including loss of productivity, high out-of-pocket (OOP) expenses, depletion of savings, and bankruptcy. Providing financial guidance and assistance through specially trained financial advocates allows hospitals, infusion centers, and cancer care clinics to mitigate the financial burdens on patients and minimize financial losses for the treating institutions.

Financial Toxicity

After a cancer diagnosis, patients and their families face many stressors, including significant short-term and long-term financial consequences. Rising insurance premiums, deductibles, coinsurance, and co-payments are directly responsible for the rising OOP costs. The combination of direct and indirect costs related to patients’ and families’ decreased work hours, or loss of employment creates a perfect storm for financial toxicity.

Many studies have shown that patients with cancer who experience financial hardship have a higher risk of treatment nonadherence, inferior quality of life, and higher mortality than those who do not experience such hardship. Thus, further supporting the desperate need for financial advocates to help mitigate the financial burden of cancer treatment.

Types of Assistance provided by Financial Advocates

Manufacturer Copay assistanceDrug Manufactures offer Copay Card assistance programs. The program’s purpose is to help patients with commercial or private insurance cover their deductibles, copays, and coinsurance directly related to their prescription drugs’ cost. Cost savings from copay assistance is paid directly to the treating institution via check or credit card. As a result, copay assistance reduces the patient’s balance and allows them to focus on adhering to their treatment plan rather than focusing on the financial burden associated with cancer treatment. In addition, the treating institution’s revenue increases by collecting the OOP expenses typically written off as bad debt.Copay Assistance through Private FoundationsFoundations offer financial assistance to those suffering from chronic or life-altering diseases when insurance coverage is insufficient. Foundations help fill the gaps by assisting patients with their out-of-pocket expenses. Medicare patients will not qualify for Manufacturer Copay Assistance Programs; however, they may be eligible for coverage through a foundation. OOP expenses generally covered through foundation assistance include oral and infusion drug costs, radiation, and blood transfusions. Copay assistance through the foundation is paid directly to the treating institution and increases revenue that otherwise would have gone to bad debt.Premium Assistance through Private FoundationsSome foundations will also cover the patient’s insurance premiums. Premium assistance allows us to help cover OOP expenses the patient has incurred that the foundation does not cover. Utilizing this benefit will ultimately reduce the patient’s balance and reduce the treating institution’s bad debt.Urgent Need Assistance through Private FoundationsAnother type of assistance provided by private foundations is urgent need and travel assistance funds. These funds open quickly and generally award smaller amounts of $250 or $500 for patients to use towards their mortgage, utility bills, transportation costs, and food. This benefit provides financial relief to patients facing hardship by covering some of their living expenses, so they do not have to choose between groceries that week or paying for their oral oncology medication.Free medication – Patient Assistance Programs (PAPs)This type of assistance helps those in need obtain their medications at no cost or very low cost. Many, but not all, pharmaceutical companies offer PAPs. Pharmaceutical companies provide free medication for oral oncology drugs delivered directly to patients or infusion oncology drugs supplied to hospitals on the patients’ behalf. Free medication is typically the last option chosen when sourcing financial assistance to patients. This option does not directly benefit the treating institution’s revenue. However, in both cases, the benefit to the hospital and the patient is minimizing bad debt collection due to unaffordable OOP expenses.

Communicating with Financial Advocates

Before beginning treatment, communication about treatment costs is key to addressing the patients’ and families’ financial issues. Treating institutions benefit greatly from collaboration with outside organizations, like Q Consulting Support Services (QCSS), with expertise in financial counseling and medical costs. Q Consulting financial advocates work alongside the treating institution’s clinical staff to increase the communication with the patient’s about their cost of treatment and how we can assist in reducing their OOP expenses.

Unfortunately, communication of treatment cost frequently falls on poorly trained staff who do not have the required education or credentials to offer true expertise in dealing with the complexities of insurance plans, treatment-related costs, and finding and sourcing financial assistance. Therefore, a high need exists to establish a relationship with advocates that can assist patients with the benefits of different types of oncology financial assistance options.

Impact of Hiring Financial Advocates

Q Consulting Support Services provides a team of highly trained advocates to identify, source, and manage the much-needed financial assistance available to oncology patients. We improve patient access to financial assistance through a systematic process for identifying patients in need and notifying them of the help available. We then obtain consent from patients, apply for financial assistance on their behalf and fully manage the entire process from claim submission to the treating institution receiving payment. QCSS utilizes proprietary software that allows us to manage the whole process seamlessly. In addition, patients are updated every step of the way and have complete access to our financial advocates to answer any questions during treatment.

By instituting a financial advocacy program through QCSS using trained financial advocates, hospitals, infusion centers, and cancer care clinics can save money that would typically have gone to bad debt. As a result, patients can gain access to care that would otherwise have been unaffordable, and overall patient satisfaction increases.

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The term financial toxicity describes how out-of-pocket (OOP) costs can cause financial problems for cancer patients. Financial Advocacy Programs help improve access to financial assistance to reduce patient debt and the need for bankruptcy.

Receiving a cancer diagnosis is burdensome enough for patients; worrying about possible financial ruin from mounting bills adds additional stressors. Cancer patients are 2 ½ times more likely to declare bankruptcy in comparison to healthy people. Additionally, according to studies from Fred Hutchinson Cancer Center in Seattle, those who declare bankruptcy are 80 percent more likely to die from the disease than other cancer patients.

Why does Cancer Create such Financial Toxicity?

Cancers occur at the cellular level, with abnormal cells diving and spreading. Physicians must contain cancer and kill the abnormal cells without damaging the nearby healthy cells to treat the disease. Treatment required often includes a range of therapies over an extended period of time, including lengthy radiation, complicated surgeries, costly chemotherapy infusions, and oral oncolytics, plus other strong medications to supercharge the immune system.

The average cost for cancer treatment in the U.S. runs about $150,000 annually. New treatments emerge daily, but with these new treatments come higher prices. According to the National Cancer Institute, cancer care in the U.S. costs $208.9 billion in 2020, increasing 10 percent from 2015 costs of $190.2 billion – an increase only due to aging and the growth of the U.S. population.

The term financial toxicity describes how out-of-pocket (OOP) costs can cause financial problems for cancer patients. The level of financial toxicity one experiences may depend on several factors in the household, including:

• Whether the patient diagnosed makes most of the money contributing to the household.
• How much money other people in the household make.
• How much debt the patient has before receiving the diagnosis.
• Assets.
• Costs related to the cancer treatment plan.
• Ability to continue working through treatment.
• Health and disability insurance and what they cover.

Cancer treatment may also affect the patient’s ability to work and pay bills. Cancer may make it hard for patients to do the physical and mental tasks required for their job. Treatment may cause the patient to miss time at work or not be able to work at all. Not working may affect the patient’s employment-based health insurance and the cost of premiums.

The type of cancer diagnosis, how severe it is, and the treatment received can also affect the risk of financial toxicity. Patients with the following types of diseases have a higher risk of financial toxicity: Advanced-stage cancer, recurrent cancer, cancer with a poor prognosis, and more than one type of cancer – partly because their cancer and treatment may keep them from having a job. Patients treated with chemotherapy and radiation therapy are more likely to have higher OOP costs and financial toxicity than patients who have not had those treatments.

Barriers to Receiving Optimal Care

There are several barriers to patients receiving optimal care; an increasing number of patients facing unaffordable OOP costs due to high deductibles, being under-insured, or uninsured.

Insurance covers much of the medical costs associated with cancer treatment. Patients with commercial plans will likely expect a bill of more than $4,000 in deductibles and copays in a year before insurance fully covers the cost of care. For Medicare patients to be adequately insured, they will need a supplemental plan to cover their annual deductible and 20 percent coinsurance, in addition to a Part D plan to cover prescription drugs associated with treatment. Medicare patients with a Part D plan will also be liable for up to $6,500 in OOP costs related to their prescriptions – which many cannot afford.

The term underinsured describes a patient with OOP health care costs that exceed ten percent of their income. Both commercially insured patients and Medicare patients can be considered underinsured.

For example, someone with Medicare A and B coverage with no supplemental plan or Part D benefit would be considered underinsured. Medicare will cover 80 percent of the treatment cost, leaving the patient with an annual deductible and 20 percent coinsurance. To better understand how this situation would affect a cancer patient, suppose a patient receives a chemotherapy infusion for Keytruda. In that case, the treating institution will bill Medicare approximately $20,000 for one infusion, Medicare will pay $16,000 to the treating institution, and the patient will be responsible for $4,000 in OOP costs. Keytruda is given every three weeks, with up to 18 infusions per year, depending upon the specific treatment plan. This example does not include the additional administrative fees that also incur the 20 percent coinsurance. The patient in this scenario would be more likely to experience financial toxicity resulting in bankruptcy without financial assistance.

Uninsured patients are those that lack any healthcare insurance. They are considered self-pay and responsible for the cost of treatment. Uninsured patients are substantially more likely to be diagnosed with cancer at a later stage when treatment can be more extensive, costlier, and less successful.

How Financial Advocacy Programs can Help

Communication about treatment costs is key to addressing the patients’ and families’ financial issues. Treating institutions benefit greatly from collaboration with outside organizations, like Q Consulting Support Services (QCSS), with expertise in financial counseling and medical costs. Q Consulting financial advocates work alongside the treating institution’s clinical staff to increase the communication with the patients about their cost of treatment and how we can assist in reducing their OOP expenses.

Q Consulting Support Services provides a team of highly trained advocates to identify, source, and manage the much-needed financial assistance available to cancer patients to avoid the downfall of financial toxicity. We improve patient access to financial assistance through a systematic process for identifying patients in need and notifying them of the help available. We then obtain consent from patients, apply for financial assistance on their behalf and fully manage the entire process from claim submission to the treating institution receiving payment. QCSS utilizes proprietary software that allows us to manage the whole process seamlessly. In addition, patients are updated every step of the way and have complete access to our financial advocates to answer any questions during treatment.

Types of Financial Assistance Utilized to Reduce Financial Toxicity

Manufacturer Copay AssistanceDrug Manufactures offer Copay Card assistance programs. The program’s purpose is to help patients with commercial or private insurance cover their deductibles, copays, and coinsurance directly related to their prescription drugs’ cost. Cost savings from copay assistance is paid directly to the treating institution via check or credit card. As a result, copay assistance reduces the patient’s balance and allows them to focus on adhering to their treatment plan rather than focusing on the financial burden of cancer treatment.Copay Assistance through Private FoundationsFoundations offer financial assistance to those diagnosed with cancer when insurance coverage is insufficient. Foundations help fill the gaps by assisting patients with their OOP expenses. Medicare patients will not qualify for Manufacturer Copay Assistance Programs; however, they may be eligible for coverage through a foundation. OOP expenses generally covered through foundation assistance include oral and infusion drug costs, radiation, and blood transfusions. Copay assistance through the foundation is paid directly to the treating institution relieving the patient of additional OOP expenses.Premium Assistance through Private FoundationsSome foundations will also cover the patient’s insurance premiums. Premium assistance is used to cover OOP expenses the patient has incurred that the foundation does not cover. Utilizing this benefit will ultimately reduce the patient’s balance and will enable them to cover other household expenses.Urgent Need Assistance through Private FoundationsAnother type of assistance provided by private foundations is urgent need and travel assistance funds. These funds open quickly and generally award smaller amounts of $250 or $500 for patients to use towards their mortgage, utility bills, transportation costs, and food. This benefit provides financial relief to patients facing hardship by covering some of their living expenses, so they do not have to choose between groceries that week or paying for their oral oncology medication.Free medication – Patient Assistance Programs (PAPs)This type of assistance helps those in need obtain their medications at no cost or very low cost. Many, but not all, pharmaceutical companies offer PAPs. Pharmaceutical companies provide free medication for oral oncology drugs delivered directly to patients or infusion oncology drugs supplied to hospitals on the patients’ behalf. This option minimizes accumulating patient bad debt that could potentially put them in the situation of declaring bankruptcy.

Avoiding Financial Ruin

The American Cancer Society estimates this year, about 609,640 Americans will die of cancer – that’s more than 1,670 people a day. Cancer is the second most common cause of death in the U.S., exceeded only by heart disease. Cancer costs us billions of dollars annually, and it also costs us the people we love. Hospitals, infusion centers, and cancer care clinics can reduce barriers to cancer care and reduce patient financial toxicity by instituting a Financial Advocacy Program through QCSS. Reducing patient financial toxicity ensures patients follow their treatment plan and take their medicine as directed, ultimately increasing the quality of life and patient outcomes. Additionally, reducing patient debt and the need for bankruptcy. Financial Advocacy programs are critical in the fight to eliminate financial ruin due to cancer.